lidocaine 5% patches — Medical Mutual
Low Back Pain
Initial criteria
- Tried at least three pharmacologic therapies, each one from a different class of medication used to treat low back pain (e.g. acetaminophen, celecoxib, NSAIDs [etodolac, meloxicam, nabumetone], muscle relaxants [carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, orphenadrine], duloxetine, gabapentin)
Reauthorization criteria
- Response to therapy required for continuation